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188 Health systems in transition France Improvements have been observed in in-hospital mortality rates (deaths within 30 days of admission) following acute myocardial infarction and ischaemic stroke. Between 1995 and 2010, 30-day mortality for all patients with acute myocardial infarction fell from 12.9% to 3.9% (Hanssen et al., 2012), while for ischaemic stroke in adults aged 45 and over the 30-day mortality deaths fell from 10.6% to 8.5% between 2005 and 2010 (OECD, 2013). Finally, the Eurobarometer survey showed a major increase in the proportion of adverse events reported (+61 percentage points) (European Commission, 2014). This may reflect better awareness by patients of the recourse available to them. A 2009 national survey of serious adverse events (événements indésirables graves) in hospitals found a frequency of 6.2 per 1000 days of hospitalization (9.2 in surgery and 4.7 in medicine), with more than 40% classified as avoidable (Table 7.1) (DREES, 2011c). Since January 2010, the surgical checklist has become part of the hospital certification process. Table 7.1 Number of adverse patient safety events identified in 2007 Adverse events ENCC ENCC PMSI PMSI Number of hospital stays Number of hospital stays Population at risk Prevalence rate (%) PSI 5: foreign body left during 75 173 7 639 056 0.08 procedure PSI 7: infections caused by IV lines 915 4 274 6 248 132 0.68 or catheters PSI 12: postoperative pulmonary 3 003 18 968 2 829 610 6.70 embolism PSI 13: postoperative sepsis 1 852 8 368 1 190 606 7.03 PSI 15: laceration or accidental puncture 1 149 6 887 7 725 975 0.89 PSI 18/19: obstetric trauma for 415 2 933 640 967 4.58 vaginal delivery Total 15 107 98 288 – – Source: Nestrigue & Or, 2011. Note: ENCC: National hospital cost scale for the acute care sector. 7.4.3 Equity of outcomes While France has achieved a good level of equality in access, particularly with respect to primary care, there is concern that the universal coverage policies introduced in the 1990s have not reduced other persisting areas of inequality. For example, the seven-year gap in life expectancy at age 35 between working class men and managers persists (Danet, 2012). Individuals in the lowest income quintile are three times more likely to report very poor health
Health systems in transition France 189 than those in the highest income quintile (Célant, Guillaume & Rochereau, 2014). In terms of mortality, regional (see Fig. 1.3) and gender (see Table 1.3) differences are apparent. Indeed, adult male mortality is more than double adult female mortality. An integrated and comprehensive policy has been argued to be the appropriate response for addressing interdependent health determinants. However, previous attempts to establish a broad intersectoral approach to health policy have faltered (see section 2.6). The Ministry in charge of Health’s 2012 National Strategy for Health emphasized the need to prioritize addressing the determinants of poor health (Ministry in charge of Health, 2013) and established a new interministerial health committee for addressing health inequalities. 7.5 Health system efficiency If the French population is willing to keep the SHI system public, the share of the population that is ready to spend more of their income on health has decreased, falling from 70% in 2010 to 55% in 2013. Indeed, improving the efficiency of the health care system to ensure the financial viability of the system is important in order to avoid the growth of the deficit and its related burden on future generations, or alternatives such increasing statutory contributions or reducing the services provided, which would adversely affect both the economy and access to care (HCAAM, 2013c). 7.5.1 Allocative efficiency In France, there is no formal mechanism of resource allocation for the overall health care system and across sectors of care as there is in the United Kingdom. The main resource allocation mechanism in place is the ONDAM, which sets the overall level of SHI expenditure and its distribution across six subsectors of care (ambulatory care, health care in hospitals paid on DRG basis, health care in other hospitals, health and social care for the elderly, health and social care for disabled people, and other types of care; see section 3.3.3). However, the ONDAM subsector targets are not necessarily based solely on population. Fig. 7.2 shows the ONDAM annual growth rate approved by the parliament and the size of the overrun or underspending for the period 1997–2012. The establishment of an Alert Committee in 2004 (see section 3.3.3) has insured greater credibility of this system and, since 2010, the overall ONDAM targets have been underspent, suggesting that the implemented SHI cost-containment measures have been successful.
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Contents Contents Preface
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Preface Preface The Health Systems
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Acknowledgements Acknowledgements T
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Abstract Abstract This analysis of
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1. Introduction 1. Introduction The
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